The Pediatrician.

Alcohol consumption by pediatric patients and their parents can have significant impact on the health and development of the children and adolescents. The pediatrician can help prevent or reduce alcohol-induced impairments by providing education and guidance about the responsible use of alcohol and by initiating early intervention if necessary.

P ediatricians deliver health ser vices to patients from birth to 21 years of age. This puts pediatri cians in an ideal position to edu cate children, adolescents, and families about the risks and problems associated with alcohol and other drug use as well as to take an active role in prevention, early identification of affected youth and fami lies, and intervention. Whereas it is rela tively easy to identify alcoholrelated problems in the most severely affected children and adolescents, the challenge for the pediatrician is to identify the more subtle problems in individuals who are in an early stage of their involvement with alcohol use and to intervene in a timely and meaningful manner. In children af fected by parental alcohol abuse, the pediatrician's task is to recognize the signs of alcoholinduced impairments and initiate appropriate treatment measures.
This article discusses the impact of alcohol use and abuse on the health of infants, children, and adolescents and the alcoholrelated problems commonly seen by the pediatrician. It also describes the role of the pediatrician in prevention, screening and indepth assessment of problem use, brief officebased interven tions, and treatment.

PREVALENCE OF ADOLESCENT ALCOHOL USE
Alcohol remains the drug of choice for adolescents. In 1992, almost 90 percent of high school seniors reported some experi ence with alcohol in the past, more than 50 percent reported use in the last month, and 3 percent reported daily use (Johnston et al. 1993). According to the same sur vey, 23 percent of adolescents often drove after excessive drinking, 17 percent re ported problems in peer relationships because of drinking, and 10 percent had been criticized by a close friend for drink ing, but only 1 percent believed they had a drinking problem.
Also, there is a trend toward earlier initiation of alcohol use (Johnston et al. 1993). The average age of first drinking alcohol outside of familysanctioned use or religious occasions is 12 years. Almost 50 percent of the sixth graders surveyed reported feeling peer pressure to try alco hol and 40 percent had drunk beer or wine, yet only 15 percent perceived any risk from drinking alcohol daily (Johnston et al. 1993). In addition, the rate of binge drinking (having five or more drinks in a row) among 10th graders increased from 21 percent in 1992 to 23 percent in 1993. This trend toward drinking at an earlier age is important because the earlier a person begins to drink or use other drugs, the greater the likelihood of related prob lems later (Yamaguchi and Kandel 1984).

Consequences of Adolescent Alcohol Consumption
Alcohol use contributes significantly to accidents, unintended injuries, homicides, and suicides, which are the leading causes of death among teenagers (Rogers and Adger 1993). Approximately 50 percent of fatal motor vehicle crashes and homi cides as well as a significant proportion of suicides are associated with alcohol use (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 1990). Post mortem studies show that almost 50 percent of adolescent victims of violent deaths had been drinking alcohol prior to their death (Abel and Zeidenberg 1985;Goodman et al. 1986). Alcohol also has been implicat ed in a majority of drownings, firerelated deaths, and fatal falls.
Of equal concern is the impact of alcohol use on the cognitive and psy chosocial development of young people. Alcohol use, abuse, and dependence contribute significantly to the burden of mental health disorders affecting adoles cents (Gans et al. 1990).
Moreover, children and adolescents who drink alcohol often engage in other risktaking behaviors. There is a correla tion between alcohol use and sexual activity for some adolescents, and most date rapes involve alcohol use by one or both partners (U.S. Department of Health and Human Services [USDHHS] 1992a). Responsible decisionmaking regarding condom use, partner selection, and sexual abstinence frequently diminishes under alcohol's influence and contributes to the spread of sexually transmitted diseases, including HIV/AIDS (USDHHS 1992a).

Consequences of Parental Alcohol Consumption
Pediatricians not only see the alcohol related problems caused by their patients' drinking but also the problems caused by parental drinking. These include cogni tive, emotional, and behavioral problems of children living in households with an alcoholic parent as well as alcoholrelated birth defects such as fetal alcohol syn drome (FAS).

Children of Alcoholics.
Approximately one in eight children in the United States has a parent with a past or current drinking problem (MacDonald and Blume 1986). Even if these children were not directly affected by prenatal alcohol exposure, they may suffer from indirect influences, such as divorce, stress at home, parental anxiety or affective disorders, and frequent changes in family or life situations. Children with alcoholic parents often underestimate their own abilities, which, in combination with actual cognitive deficits or academic problems, can affect their motivation, self esteem, and academic performance (Bennett et al. 1988). These children also report higher levels of depression and anxiety, exhibit increased symptoms of stress, and generally have more behavioral problems of all types than other children.
Children with alcoholic parents often come to pediatricians with recurring and vague symptoms, such as fatigue, abdom inal pain, or musculoskeletal complaints, which are indicative of psychosomatic illness (MacDonald and Blume 1986). In addition, they may suffer from accidental injuries, verbal assault, physical abuse, or incest caused by parental drinking. Pediatricians can help influence these families because of their understanding of family dynamics and close, longstanding relationships with the families.

AlcoholRelated Birth Defects.
Between 8 and 11 percent of women of childbear ing age are either problem drinkers or alcoholics, and approximately 2.6 million infants are born annually following signif icant intrauterine exposure to alcohol (Wilsnack and Wilsnack 1991). The most notable postnatal effect of significant intrauterine alcohol exposure is FAS. With an incidence estimated at 1.9 cases per 1,000 live births (NIAAA 1993), FAS is the leading known cause of mental retardation in the United States, surpass ing Down syndrome.
The term "FAS" refers to a pattern of abnormalities in children of alcoholabusing mothers. One of the most common mani festations is fetal growth retardation, with weight, length, and head circumference below the 10th percentile for the age group. Also characteristic are facial ab normalities such as small eye openings, a low nasal bridge, an elongated and flat tened midface and philtrum (the zone between nose and mouth), and a thin upper lip (NIAAA 1993). The most dev astating result of FAS is central nervous system dysfunction, including delayed development, hyperactivity, attention deficits, mental retardation, and seizures.
A longterm followup study of the consequences of FAS illustrated that it is not just a childhood disorder; there are predictable, longlasting effects with physical, mental, and behavioral implica tions that persist beyond adolescence into adulthood (Streissguth et al. 1991). Ado lescent and adult FAS patients (ages 12 to 40) were found still to have reduced height and head circumference, although the weight deficiency and the characteris tic facial features were less marked. Most importantly, the cognitive and develop mental handicaps of these FAS patients remained profound, and the majority of patients had maladaptive behaviors such as attentiondeficit disorder.
The constellation of features labeled FAS represents the severe end of a contin uum of disabilities attributed to maternal alcohol use during pregnancy but does not include all affected individuals. The prev alence of the more subtle consequences, termed "fetal alcohol effects" (FAE), is estimated to be significantly higher (NIAAA 1993). Therefore, although FAS is identified more frequently, the more prevalent alcoholinduced cognitive and behavioral effects of FAE may be the more serious public health problem.

RISK FACTORS FOR ALCOHOL USE PROBLEMS
Biological, psychological, and social risk factors (see box on p. 123) can contribute to the development of alcohol abuse and alcoholrelated problems in children and adolescents. For example, genetic predispo sition (i.e., a family history of alcoholism) is a wellestablished biological risk factor. Studies have shown that children of alco holics are four to five times more likely to develop alcohol dependence than are other children (USDHHS 1992b).
Psychological factors contributing to alcoholrelated problems are less well understood. However, children and ado lescents with significant problems with behavior (e.g., aggressiveness, rebellious ness, and delinquency), cognition (e.g., learning disabilities and attentiondeficit disorders), psychological wellbeing (e.g., depression, isolation, and low self esteem), and family functioning (e.g., neglect, abuse, and loss or lack of close relationships) have been shown to be at increased risk for alcohol use problems (Kumpfer 1989;Werner 1991).
Certain family and social influences also have been identified as risk factors for alcohol use disorders or related prob lems. Kumpfer (1989) and Werner (1991) noted that children whose parents drink alcohol are more likely to drink them selves than are children whose parents do not drink. Other family determinants affecting children's or adolescents' drink ing behavior include lack of parentchild interactions and maladaptive family prob lemsolving, which often involve avoid ance of issues and conflict. Families with marital discord, financial strains, social isolation, and disrupted family rituals (e.g., meal times, holidays, and vacations) also increase an adolescent's risk for problem alcohol use.
On the other hand, some family char acteristics are considered protective fac tors against adolescent problem alcohol use. Adolescents least likely to use alco hol and other drugs are emotionally close to their parents, receive advice and guid ance from their parents, have siblings who are intolerant of drug use, and are expect ed to comply with established rules of conduct (Hawkins and Fitzgibbon 1993). The parents of nonusers typically provide praise and encouragement, engender feelings of trust, and are sensitive to their children's emotional needs.

ROLE OF THE PEDIATRICIAN
The Committee on Substance Abuse of the American Academy of Pediatrics (AAP) recommends that pediatricians include substance abuse in their anticipatory guid ance (discussed below) to all children and adolescents (Schuydower et al. 1993). To fulfill this role adequately, pediatricians must develop interviewing and counseling skills to recognize risk factors and signs of substance abuse in preadolescent and adolescent patients. In addition, they must learn to perform an individualized assess ment of "normal" versus "problematic" behavior and to initiate appropriate inter ventions or referral.
The Guidelines for Adolescent Preven tive Services (GAPS), established by the American Medical Association, recom mends both primary (e.g., patient educa tion and anticipatory guidance) and secondary (e.g., early intervention) pre vention strategies to reduce adolescent use of alcohol and other drugs, including steroids (Elster and Kuznets 1994). These measures include screening all children and adolescents and using brief counsel ing interventions and referral as needed. GAPS also recommends that pediatricians routinely ascertain their patients' risk factors (including a family history of alcoholism) in the medical history and conduct screening evaluations for all schoolaged children and adolescents.

Anticipatory Guidance and Prevention
The role of the pediatrician in preventing alcoholrelated problems begins early in a child's life, ideally during neonatal visits, by educating the parents about their re sponsibilities and the influence of their

RISK FACTORS FOR ALCOHOL ABUSE
Numerous biological, psychological, and social factors can determine whether an adolescent is at increased risk for developing alcohol abuse pat terns and alcoholrelated problems.
Family history of alcoholism or other drug abuse Depression and other psychiatric conditions Loss of loved one Low selfesteem Poor social skills School problems Low expectations for school Family tolerance for deviance Peer tolerance for deviance lifestyle and alcohol use on the infant, child, and adolescent and by exploring their attitude toward alcohol use. Parents need to be aware that their attitudes and beliefs can strongly influence their child's behavior.
Attitudes and beliefs regarding alcohol develop early in life, often by age 7 or 8 (Gaines and Brooks 1988). Therefore, wellchild visits during the early school years allow the pediatrician to begin anticipatory guidance and to talk with children and parents about alcohol use. Pediatricians can initiate or enhance the dialog between children and their parents by asking if alcohol use is discussed in school, inquiring about the specifics of what is being taught, and assessing if the child understands the messages that are being delivered. It is important to ask if alcohol use is discussed among friends, whether alcohol is present in the child's environment, and about the child's per ceptions of why some people drink and whether alcohol use is harmful.
In addition to providing anticipatory guidance to individual patients, pediatri cians can play an active role in general prevention programs directed at children and adolescents. Pediatricians can act as important advocates for appropriate community and schoolbased prevention approaches (Comerci and MacDonald 1990), ensuring that local programs are culturally relevant and appropriate for the community and population they serve.
Some of the most frequently used gen eral prevention approaches in community and schoolbased programs focus on deterring initial alcohol and other drug use (Comerci and MacDonald 1990;Hawkins and Fitzgibbon 1993). Although their content may vary, these approaches encompass problemsolving, decisionmak ing, interpersonal skills, assertiveness training, cognitive skills for resisting social pressures, and drugfree coping alternatives. These skills are taught through demonstration, rehearsal, or homework assignments.

Recognition of AlcoholRelated Problems
Pediatric patients show different degrees of participation with alcohol, from con templating or experimenting with alcohol use to being involved with alcohol to a harmful degree or alcohol dependent (MacDonald 1984;Adger 1991). The challenge for the pediatrician is to recog nize and, if necessary, counteract these different stages of alcohol use and abuse.
The signs and symptoms of alcohol abuse in adolescents often are subtle, indicated only by behavioral dysfunctions. Adolescents at a stage of initial or experi mental use may not yet display any behav ioral changes or discernible consequences. But alcoholrelated symptoms and associ ated consequences, such as falling grades; a sudden lapse in school attendance; and problems with interpersonal relationships, family, or the law may become evident as alcohol use increases. Other symptoms include weight loss, change in sleep habits and energy level, depressed mood or mood swings, and suicidal thoughts or suicide attempts. Because of this wide variety of symptoms, the pediatrician must consider alcohol use as a potential cause for all behavioral, family, psychosocial, or related medical problems.

Routine Screening.
Pediatricians should screen all patients for alcohol use and determine the need for further assessment and intervention. Potential risk factors and behaviors should be reviewed with the patients and their parents as a routine part of each pediatric visit. Pediatricians also should address environmental stres sors, social pressures, and family attitudes and practices, which play an important role in shaping the attitudes and behaviors of young people.
Although there is no broad acceptance of any one screening strategy in a pediatric setting, several approaches to office screening and assessment of alcohol and other drug use are available and offer guidance for the pediatrician (Anglin 1987;Bailey 1989;Farrow and Deisher 1986;Alderman et al. 1992; see this page for guidelines for the screening interview).
Several authors recommend using the CAGE test (see Nilssen and Cone,, a widely used screening question naire that can be modified to meet the needs of the adult or pediatric patient (e.g., Mac Donald 1986). The four CAGE questions are short and simple and can be incorporated easily into taking the medical history.
In addition to being useful for screen ing an adolescent's alcohol use directly, the CAGE questions also can provide a proxy report regarding another person. They can be adapted to reveal the percep tions of others about the adolescent's use of alcohol or the alcohol use of a parent or significant other. For example, the pediatri cian could use the CAGE questions in the following manner with a child or adoles cent who is not using alcohol but seems concerned about a parent's use of alcohol: Begin with discussion of more general lifestyle questions that include the topic areas of home and family relationships, functioning at school, peer relationships, leisure activities and employment, and self-perception.

Ask about dietary patterns.
Proceed to questions about prescribed medications.
Ask about over-the-counter medications.
Ask about cigarette and smokeless tobacco use.
Ask about alcohol use.
Ask about marijuana use.
Finally, ask about any illicit drug use.
Allows time to develop or renew patient/physician relationship. Provides basis (through general psychosocial information) to determine patient's risk for harmful environment.
Start with least threatening questions.
Move to increasingly sensitive substances.
Products that relieve symptoms of upper respiratory infections and allergic rhinitis or promote wakefulness, indigestion remedies, analgesics, hypnotics, and topical eye drops are used commonly by substance-abusing adolescents.
This order of questioning provides a natural order of progression, moving from the socially accepted . . . to the socially tolerated . . . to the socially disapproved . . .
to the overtly illegal.
(AAIS), Personal Experience Screening Questionnaire (PESQ), Children of Alco holics Screening Test (CAST), and the Substance Abuse Subtle Screening Inven tory (SASSI). Another instrument that helps to evaluate multiple problem areas and can be adapted easily to the office setting is the Problem Oriented Screening Instrument for Teenagers (POSIT) (for an overview, see Comerci 1993). The use of specific interviewing techniques and questionnaires to obtain information about adolescent alcohol con sumption remains an area of active dis cussion. Whatever approach is used, the acquisition of accurate and meaningful information from the child or adolescent will depend largely on the degree to which trust is established and the patient perceives the pediatrician as caring, em pathetic, and knowledgeable.

Assessment.
Screening interviews are only an important and timesaving first step to identifying an alcohol problem. A positive screening result indicates the need for an indepth assessment and a formal diagnosis. Assessment is a more lengthy and structured process designed to determine the extent of the problem, explore coexisting medical and psychi atric conditions, and assist in treatment planning (see box on p. 125).
A comprehensive assessment requires information about the physiological, psy chological, behavioral, and social aspects of the patient's life. Because of this broad scope, assessment and diagnosis may be beyond the time limitations and skills of most practitioners. The pediatricians may therefore choose to make a referral to a skilled alcohol abuse specialist.

Brief OfficeBased Interventions
Early intervention is directed at patients whose use of alcohol, tobacco, or other drugs places them at an unacceptably high risk for negative consequences or has resulted in clinically significant dysfunc tions or consequences and at patients or families who exhibit specific problem behaviors considered to be precursors to alcohol problems (Klitzner et al. 1992). The rationale for these interventions is that health messages provided by pediatri cians can effect behavioral changes in adolescents because the physician is considered a source of credible informa tion. These messages can be especially effective if they reinforce information already received in other settings from  Manual, 1994. teachers, parents, and other adults (Pentz 1993). Personalized interactions with the adolescent in an office setting also may have a greater impact than preventive interventions provided in group settings or through mass media.

DIFFERENCES BETWEEN SCREENING AND ASSESSMENT INTERVIEWS
Interventions for alcohol problems should provide adolescents with the nec essary information, skills, and support to change their behavior. The primary impact of brief interventions is motivationaltriggering a decision and commitment to change. Brief interventions typically have three common elements.
First, after an initial evaluation, the patient is given structured feedback about the screening results. This provides the patient with an opportunity to reflect in detail on his or her present situation.
Second, the pediatrician clearly advis es the patient to make a change toward a specific goal, such as total abstinence, elimination of hazardous use, or enter ing treatment. The patient also can be presented with a menu of alternative strategies for changing drinking behavior. Although pediatricians should support the primary objective of abstinence by ado lescents under the age of 21, the most urgent message-in terms of both imme diate and lifetime behaviors to reduce morbidity and mortality-is to not drink and drive or ride with others who drink and drive (Beach 1991).
Third, the patient's responsibility for change is emphasized, often through explicit messages, for example, "It's up to you to decide what to do with this situa tion. Nobody can decide for you, and no one can change your drinking if you don't want to change." The essential officebased interventions for alcohol problems include the following: • Ask older children and adolescents about their awareness of and use of alcohol.
• Ask about the use of alcohol by the patient's friends.
• Ask if the adolescent has ever driven while under the influence of alcohol or ridden with someone who was under the influence.
• Have the adolescent commit to a firm nodrinkinganddriving policy.
• Help families develop saferide poli cies before they are needed.
• Screen for alcohol use problems as part of the evaluation of all patients who sustained accidental trauma or were in motor vehicle crashes.
• Identify and refer substanceabusing patients or family members.
Not only the kind of advice but also the way in which it is delivered is important. Effective brief interventions emphasize the supportive nature of the physicianpatient relationship and seek to reinforce the patient's selfefficacy or optimism. Overly directive and confronta tional styles tend to evoke high levels of patient resistance, whereas a more empa thetic style is associated with less resis tance and better longterm change (Miller and Rollnick 1991).

Treatment
The role of the pediatrician in treating alcoholrelated problems varies consider ably. A significant function is to assist the patients and their families in selecting the appropriate treatment program. Several treatment alternatives exist for alcohol dependent children and adolescents, including shortterm inpatient treatment; residential programs; and outpatient care, which spans the spectrum from office based care to intensive and structured day programs (AAP 1990).
It is important for the pediatrician to be aware of the different treatment pro grams and resources in the community and their particular treatment philosophies. Although most treatment programs begin with the interruption of alcohol use, require continued abstinence from alcohol, and have the goal of a drugfree lifestyle, there is a wide variety of settings and several approaches to treating children and adoles cents. The AAP (1990) has issued guide lines for evaluating substance abuse treatment programs.
There has been little treatment out come research evaluating the impact or therapeutic benefit of particular treatment approaches in adolescents. According to a recent Institute of Medicine report, the state of knowledge about adolescent treat ment is less than satisfactory. The number of studies on adolescents is small, and most work is based on older treatment models. Hence, there is a need for studies that specifically address assessment of alcoholrelated problems in children and adolescents and matching of appropriate treatment with the level of involvement and severity of consequences.

CONCLUSION
Pediatricians encounter children, adoles cents, and families suffering from alcohol related problems of various kinds and intensities. The challenge for the physi cian is to detect patients at risk for or in early stages of alcohol abuse. Therefore, pediatricians must be acutely aware of the many avenues by which alcohol problems affecting children and adolescents present themselves. By including routine screen ing tests in their practice and initiating appropriate interventions or referrals, pediatricians can make a difference in the longterm health and development of their patients. ■